The health of Americans has improved significantly over the past 50 years, as evidenced by an increased lifespan and lower infant and adult mortality rates. However, Black Americans and other racial/ethnic minority groups are still at greater risk for early mortality and morbidity from a range of chronic health conditions such as diabetes, hypertension, obesity, asthma, and heart disease compared with White Americans.1,2 Evidence suggests that these health disparities stem from structural racism, as well as provider implicit bias or unconscious bias, that factors into judgments and influences clinical decision-making.1
Moreover, these health disparities cannot be accounted for by socioeconomic factors alone. The COVID-19 pandemic further underscored these health disparities, as minority populations were disproportionately affected by the illness in the first 2 years of the pandemic.1
Health Disparity: Part of American History
Prior to the Civil War, physicians, scientists, and slave owners perpetuated beliefs in the physical dissimilarities between Black and White populations as a way to justify slavery.3 These beliefs are still held today. A 2016 survey found that almost 50% of White medical students and residents admitted to false beliefs regarding biologic variances between White and Black patients.4
It is crucial to understand racial inequalities in medical treatment. The term “racism” refers to a system based on a discriminative mentality that classifies and ranks the human population in stereotypical ways and allocates societal resources accordingly (Table 1).5,6 At the individual level, this may or may not be accompanied by bias, whether conscious or unconscious. These untrue opinions may influence medical decisions and contribute to racial disparities in health-related outcomes.3-4
Table 1. Definitions5,6
|Race||Any one of the groups that humans are often divided into based on physical traits regarded as common among people of shared ancestry|
|Racial disparity||The imbalances and incongruities between the treatment of racial groups including economic status, income, housing options, societal treatment, safety, and other aspects of life and society|
|Racism||A system based on a discriminative mentality that classifies and ranks the human population in stereotypical ways and allocates societal resources accordingly|
|Implicit bias||A bias of prejudice that is present but not consciously held or recognized|
Distrust of the medical profession by Black patients can be traced back to when Black individuals were used for experimental procedures, surgeries, and dissections. For example, in the 1800s, James Marion Sims, MD, known as the “father of modern gynecology,” performed gynecologic surgical procedures on unanesthetized Black women.5 More recently, the Tuskegee Syphilis Study has contributed to fear and mistrust among patients and vestiges of the belief that Black people are less than human, which is still rooted in America today.7
Distrust of medical professionals, false beliefs, social disadvantages, clinician bias, and a discriminative health care system all contribute to ethnic and racial disparities. According to Fiscella and Sanders, “Separate and unequal systems of health care between states, between health care systems, and between clinicians constrain the resources that are available to meet the needs of disadvantaged groups, contribute to unequal outcomes, and reinforce implicit bias.”8
To counter implicit and unconscious bias, initiatives beyond diversity and cultural competency training are needed. PAs and nurse practitioners (NPs) can positively impact disparities by building trust and respect while promoting equity and justice in the health care system. Medical students, including PA and nursing students, should be offered courses that promote cultural awareness in patient care and help to develop vital communication and clinical skills related to reducing negative associations, which can affect judgment and behavior.9
Health Disparities Related to Implicit Bias
Implicit bias refers to an individual’s unconscious or conscious perceptions, stereotypes, and beliefs of others. Subconscious beliefs can cause one to speak or act in ways contrary to their conscious principles. These biases can be positive or negative and may raise serious concerns in health care. The implicit bias of health care providers can adversely affect their medical decision-making, severely impacting an already underprivileged population.10
Maina et al found that 8 of 14 studies (57%) that explored the relationship between implicit bias and health care outcomes using clinical scenarios or simulated patients found no statistically significant relationship between implicit bias and patient care.10 However, 6 studies found that higher implicit bias was correlated with disparities in treatment recommendations, expectations of therapeutic bonds, pain management, and empathy. Half of the studies examined the impact of implicit provider bias on real-world, patient-provider interaction and found that providers with more pronounced implicit bias demonstrated poorer patient-provider communication.10
A provider’s ability to empathize with a patient can enhance their ability to deliver high-quality and competent care. A positive interaction between clinicians and patients can influence the likelihood of a patient adhering to medical treatments. It also helps these patients understand and participate in their care. However, Roberts et al found that patients with low socioeconomic status rated their clinicians’ empathy scores as lower than those reported by patients not of low socioeconomic status (mean difference, -0.87 [95% CI, -1.72 to -0.02]).11
Moreover, race or ethnicity is also factored into some of the strategies and calculations applied by practitioners when administering treatment and medications. As a result of this implicit bias, Black patients may be less likely to receive specific medicines, transplants, and specialist referrals. For example, study findings show that minorities are less likely to be prescribed pain relief medications by doctors. Specifically, an analysis of data from 350 emergency departments in the US found that non-White patients were 22% to 30% less likely to receive analgesic medication and 17% to 30% less likely to receive opioids compared to their White counterparts.12
Another trickle-down effect of implicit bias is that a health care provider might not issue a referral for an uninsured patient to a specialty clinic if there is no system of care for uninsured patients in the local community. In addition, a patient may not visit a specialist if the clinic is too far away from their home or if the out-of-pocket costs are too high. Also, minority populations often have limited access to health care, particularly preventative care, early intervention, and effective management of chronic illness, which play a fundamental role in optimal health-related outcomes. As a result, disparities in the quality and quantity of treatment among different racial and ethnic groups contribute to racial health disparities.
Even among minority patients who do have access to health care, the quality of that care is decreased compared with that among White patients. The 2021 National Healthcare Quality and Disparities Report found worse quality of care among Black vs White patients for 11 out of 29 (38%) patient safety measures, 18 out of 43 (42%) effectiveness of care measures, and 32 out of 72 (44%) healthy living measures (Table 2).13
Table 2. Measures With Worse Outcomes for Black Patients
|Cervical cancer diagnosed at an advanced age|
|Colorectal cancer diagnosed at an advanced age; colorectal cancer deaths|
|Breast cancer diagnosed at an advanced age; breast cancer deaths|
|Children with obesity|
|Vaccination (pneumococcal in older adults, influenza in adults, diphtheria-tetanus-pertussis) in children ages 19-35 months|
|Postoperative respiratory failure, acute kidney injury requiring dialysis, or sepsis following elective surgical hospital discharges in adults|
|Hospital admissions for urinary tract infection (UTI)|
|Hospital admissions for short-term complications of diabetes in children and short- or long-term complications of diabetes in adults|
|Hospital admissions for asthma in children and adults|
|Hospital admissions for hypertension in adults|
|Hospital admissions for heart failure|
|New HIV cases and HIV-related deaths|
|Treatment for depression in adults with a major depressive episode in the last year|
|Children given advice on healthy eating in the past 2 years|
|Children and adults with a dental visit in the past year|
An illustration of health disparity is the disproportionate effects of the COVID-19 pandemic on racial and ethnic minority communities during the early stages of the pandemic when the death rate for Black Americans was almost 2-fold higher than that for White Americans (Figure).14,15 The death rate among Latino populations was also higher than that for White individuals. The pandemic also showed the effects that concerted outreach efforts can have on balancing out health disparities as this statistic has changed and White Americans now have a 14% higher COVID-19 death rate compared with Black Americans and a 72% higher rate than that among Latino Americas, according to the latest data from the Centers for Disease Control and Prevention. Among the successful outreach efforts were those that lead to an increase in vaccination rates over the 18 months.
Another recent correction of implicit bias in health care is the removal of race from the calculation of estimated glomerular filtration rate (eGFR) recommended by the National Kidney Foundation (NKF)–American Society of Nephrology (ASN) Task Force in 2021.16 The inclusion of race in eGFR estimations has been linked to disparities in care such as delays in kidney disease diagnosis and the eligibility for kidney transplantation.17
Thus, negative biases toward marginalized groups give rise to social disadvantages and imbalances and, in some cases, poor health outcomes. Health care disparities signify the failure of this system at many levels. However, change can be made.
What Can Providers Do?
With the knowledge that unconscious bias exists, measuring and mitigating its effect is a new area of focus that is needed for health care professionals.18 Amazon, Microsoft, and Zillow have announced plans and initiatives to increase Black representation in their boardrooms and CEO positions.19 In health care, more than “just” diversity training and cultural competency training is needed — organizations like DNPs of Color are calling for more people of color in the C-suites of hospitals and health care systems. Similar to Fortune 500 companies, health care providers need to modernize their approach to understanding cultures that they are not familiar with. Individual strategies of reflection, mentorship, and sponsorship initiatives as well as a commitment to cultural awareness and humility are some of the proposed calls to action.20 In medicine, it is so easy to link a specific behavior or disease pattern to a specific racial/ethnic group and this may lead to negative attitudes toward certain minority populations. Clinicians must commit to the normalcy of treating all patients equally.
Research suggests that biased behaviors increase during medical education in part because of biases shown by professors that are picked up by medical/nursing students.21 Medical education is also missing the mark in terms of representation of diverse patients in core medical courses. The Mayo Clinic has targeted bias in medical education by studying the environment and training provided in 49 medical schools in the US and the change in student attitudes and values over time.22 As noted previously, positive interaction with health care providers can improve patients’ attitudes surrounding their medical care and improve communication, trust, and knowledge. Learning to connect with patients by understanding their perspectives begins in the classroom. Through the development of practical and tangible clinical skills and learning exercises, students can practice vital communication skills before using these skills in clinical settings with patients.23 This type of training may be provided annually instead of as a one-time workshop. In addition to promoting clinicians’ awareness of implicit biases, training also can offer strategies to reduce associations and even control the influence of such associations on judgment and behavior.
For practicing clinicians, the American Medical Association (AMA) and the American Academy of Family Practice (AAFP) have developed strategies for clinicians to address possible bias. These include debiasing techniques through training, taking the perspective of others, emotional expression, counter stereotypical exemplars, and intergroup contact.24,25
Despite significant advances in the diagnosis and treatment of medical conditions, Black Americans and other minority groups, on average, tend to receive lower-quality health care and have greater morbidity and mortality rates compared with White Americans. This is primarily because of the long-term effects of racism regardless of one’s socioeconomic status. Health disparities can be reversed; however, it will require authentic commitment to remove racial bias and improve training from medical/nursing school through practice.
Recently, the attitudes and biases of health care professionals toward disadvantaged groups have become the focus of research. As the United States becomes more diverse, racial bias and discrimination may increase as well; thus, continued research on implicit bias is required. All providers should be aware of their bias when providing care to patients as this can affect patient outcomes. Mitigating personal bias and improving clinician perceptions are self-directed pursuits and require reflection and commitment to counter stereotypes.
|Institute for Healthcare Improvement |
• How to reduce implicit bias
• How can providers reduce unconscious bias?
• Does racism play a role in health inequities?
|Sukhera et al. Implicit bias in health professions: from recognition to transformation.|
|Murry-Garicia J. Cultural humility and the prehealth professional student.|
|Edgoose et al. How to identify, understand, and unlearn implicit bias in patient care.|
|Association of American Medical Colleges. Unconscious bias resources for health professionals.|
Leah D. Moss, PA-C, DMSc, MSPAS, is a Navy physician assistant.
- Racism and health. Centers for Disease Control and Prevention. Updated November 24, 2021. Accessed June 15, 2022. https://www.cdc.gov/healthequity/racism-disparities/index.html
- Kochanek KD, Anderson RN, Arias E. Leading causes of death contributing to decrease in life expectancy gap between black and white populations: United States, 1999-2013. NCHS Data Brief. 2015;(218):1-8.
- American medicine was built on the backs of slaves. and it still affects how doctors treat patients today. The Washington Post. June 4, 2021. Accessed June 15, 2021. https://www.washingtonpost.com/news/made-by-history/wp/2018/06/04/american-medicine-was-built-on-the-backs-of-slaves-and-it-still-affects-how-doctors-treat-patients-today/
- (old 4) Hoffman KM, Trawalter S, Axt JR, Oliver MN. Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites. Proc Natl Acad Sci U S A. 2016;113(16):4296-301. doi:10.1073/pnas.1516047113
- Merriam-Webster’s Collegiate Dictionary. 11th ed. Merriam-Webster Inc; 2003. [continuously updated] https://merriam-webster.com
- Social justice guide. Howard University School of Law. Accessed June 21, 2022. https://library.law.howard.edu/socialjustice/disparity
- Thomas SB, Casper E. The burdens of race and history on black people’s health 400 years after Jamestown. Am J Public Health. 2019;109(10):1346-1347. doi:10.2105/AJPH.2019.305290
- Fiscella K, Sanders MR. Racial and ethnic disparities in the quality of health care. Annu Rev Public Health. 2016;37:375–394. doi:10.1146/annurev-publhealth-032315-021439
- Dehon E, Weiss N, Jones J, Faulconer W, Hinton E, Sterling S. A systematic review of the impact of physician implicit racial bias on clinical decision making. Acad Emerg Med. 2017;24(8):895-904. doi:10.1111/acem.13214
- Maina IW, Belton TD, Ginzberg S, Singh A, Johnson TJ. A decade of studying implicit racial/ethnic bias in healthcare providers using the implicit association test. Soc Sci Med. 2018;199:219-229. doi:10.1016/j.socscimed.2017.05.009
- Roberts BW, Puri NK, Trzeciak CJ, Mazzarelli AJ, Trzeciak S. Socioeconomic, racial and ethnic differences in patient experience of clinician empathy: Results of a systematic review and meta-analysis. PLoS One. 2021;16(3):e0247259. doi:10.1371/journal.pone.0247259
- Shah AA, Zogg CK, Zafar SN, et al. Analgesic access for acute abdominal pain in the emergency department among racial/ethnic minority patients: a nationwide examination. Med Care. 2015;53(12):1000-1009. doi:10.1097/MLR.0000000000000444
- 2021 National Healthcare Quality and Disparities Report. Agency for Healthcare Research and Quality. Updated January 2022. Accessed June 21, 2022. https://www.ahrq.gov/research/findings/nhqrdr/nhqdr21/index.html
- COVID-19 weekly cases and deaths per 100,000 population by age, race/ethnicity, and sex. Centers for Disease Control and Prevention. Accessed June 13, 2022. https://covid.cdc.gov/covid-data-tracker/#demographicsovertime
- Leonhardt D. Covid and race. New York Times. June 9, 2022. Accessed June 13, 2022. https://www.nytimes.com/2022/06/09/briefing/covid-race-deaths-america.html
- Delgado C, Baweja M, Crews DC, et al. A unifying approach for GFR estimation: recommendations of the NKF-ASN Task Force on Reassessing the Inclusion of Race in Diagnosing Kidney Disease. Am J Kidney Dis. 2022;79(2):268-288.e1. doi:10.1053/j.ajkd.2021.08.003
- Eneanya ND, Yang W, Reese PP. Reconsidering the consequences of using race to estimate kidney function. JAMA. 2019;322(2):113-114. doi:10.1001/jama.2019.5774
- Blair IV, Steiner JF, Havranek EP. Unconscious (implicit) bias and health disparities: where do we go from here? Perm J. 2011 Spring;15(2):71-78.
- Amazon, Microsoft, and Zillow are backing an initiative to increase black representation on corporate boards. CNN. October 7, 2021. Accessed June 15, 2021. https://edition.cnn.com/2021/06/03/investing/corporate-diversity-black-boardroom-initiative/index.html
- Kerner J, McCoy B, Gilbo N, Colavita M, Kim M, Zaval L, Rotter M. Racial disparity in the clinical risk assessment. Community Ment Health J. 2020;56(4):586-591. doi:10.1007/s10597-019-00516-3
- Nolen L. How medical education is missing the bull’s-eye. N Engl J Med. 2020 25;382(26):2489-2491. doi:10.1056/NEJMp1915891
- Targeting unconscious bias in health care. Mayo Clinic News Network. April 21, 2015. Accessed June 15, 2022. https://newsnetwork.mayoclinic.org/discussion/targeting-unconscious-bias-in-health-care/
- Zestcott CA, Blair IV, Stone J. Examining the presence, consequences, and reduction of implicit bias in health care: a narrative review. Group Process Intergroup Relat. 2016;19(4):528-542. doi:10.1177/1368430216642029
- Implicit bias. American Academy of Family Physicians. Accessed June 6, 2022. https://www.aafp.org/about/policies/all/implicit-bias.html
- Health equity education center. American Medical Association. Accessed June 6, 2022. https://edhub.ama-assn.org/health-equity-ed-center